Biomedicine & Pharmacotherapy 142 (2021) 112021

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Biomedicine & Pharmacotherapy

journal homepage: www.elsevier.com/locate/biopha

Hidden pharmacological activities of valproic acid: A new insight

Dhirendra Singh a, Sumeet Gupta a, *, Inderjeet Verma a, Mohamed A. Morsy b, c, Anroop B. Nair b,
Al-Shaimaa F. Ahmed d
a
Department of Pharmacology, M.M. College of Pharmacy, M.M. (Deemed to be University), Mullana, Ambala, Haryana, India
b
Department of Pharmaceutical Sciences, College of Clinical Pharmacy, King Faisal University, Al-Ahsa, Saudi Arabia
c
Department of Pharmacology, Faculty of Medicine, Minia University, El-Minia, Egypt
d
Department of Pharmacology and Toxicology, Faculty of Pharmacy, Minia University, El-Minia, Egypt

A R T I C L E I N F O A B S T R A C T

Keywords: Valproic acid (VPA) is an approved drug for managing epileptic seizures, bipolar disorders, and migraine. VPA
Valproic acid has been shown to elevate the level of gamma-aminobutyric acid (GABA) in the brain through competitive in­
Histone deacetylases hibition of GABA transaminase, thus promoting the availability of synaptic GABA and facilitating GABA-
Diabetes mellitus
mediated responses. VPA, which is a small chain of fatty acids, prevents histone deacetylases (HDACs).
Renal protection
Cardiac remodeling
HDACs play a crucial role in chromatin remodeling and gene expression through posttranslational changes of
Muscular dystrophy chromatin-associated histones. Recent studies reported a possible effect of VPA against particular types of
cancers. This effect was partially attributed to its role in regulating epigenetic modifications through the inhi­
bition of HDACs, which affect the expression of genes associated with cell cycle control, cellular differentiation,
and apoptosis. In this review, we summarize the current information on the actions of VPA in diseases such as
diabetes mellitus, kidney disorders, neurodegenerative diseases, muscular dystrophy, and cardiovascular
disorders.

1. Introduction
Valproic acid (VPA), commonly known as valproate, is among the
most commonly prescribed antiepileptic drugs [1]. Globally, approxi­
mately one million people consume VPA daily [2]. VPA is an analog of
valeric acid (a natural product obtained from Valeriana officinalis, syn­
thesized by Beverly S. Burton in 1882 to be used as a solvent [3]). The
antiepileptic action of VPA was discovered in 1962 by Pierre Eymard
[4]. In 1967, VPA was officially approved in France as an antiepileptic
agent. It is currently approved in more than one hundred countries [5].
VPA is also used for other indications including, migraine headache,
bipolar disorder, and as a protective agent against diabetic neuropathy
[6].
VPA acts by potentiating the effect of the inhibitory transmitter
gamma-aminobutyric acid (GABA) via prevention of GABA degradation,
suppression of GABA transamination action, and promotion of GABA
synthesis [7]. Additionally, VPA prolongs the N-methyl-­
D-aspartate-mediated stimulation with inhibition of calcium and sodium
channels [8]. Moreover, an effect of VPA, which was attributed to its
action on histone deacetylase (HDAC), was reported against leukemia
and a few solid tumors. VPA was also shown to exhibit cell-specific
selectivity by attenuating HDAC6 and HDAC8 activity in a model of
cardiac hypertrophy [9]. Collectively, it is clear that VPA exerts multiple
actions through different mechanisms; thus, the review aims to highlight
and discuss its new pharmacological actions.
2. Actions on the CNS
VPA, an FDA-approved antiepileptic drug, is a propyl substituent on
a pentanoic acid stem [10]. It is the drug of choice in treating general­
ized or partial epilepsies, primarily for the management of absence
seizures [11]. It modulates neuronal discharge by enhancing GABA
levels in pre and postsynaptic neurons. The binding of GABA to its own
receptor leads to chloride ion influx into the postsynaptic neuron,
leading to hyperpolarization of the neurons [12]. VPA enhances GABA
action by enhancing its synthesis by increasing glutamic acid

Abbreviations: CHOP, lowered C/EBP-homologous protein; GABA, gamma-aminobutyric acid; GRP78, glucose-regulated protein 78; HDACs, histone deacetylases;
HSP, heat shock protein; ROS, reactive oxygen species; T1DM, type 1 diabetes mellitus; VPA, valproic acid.
* Corresponding author.
E-mail address: sumeetgupta25@gmail.com (S. Gupta).

https://doi.org/10.1016/j.biopha.2021.112021
Received 4 April 2021; Received in revised form 28 July 2021; Accepted 7 August 2021
Available online 25 August 2021
0753-3322/© 2021 The Author. Published by Elsevier Masson SAS. This is an open access article under the CC BY-NC-ND license
(http://creativecommons.org/licenses/by-nc-nd/4.0/).
D. Singh et al.
decarboxylase, an enzyme involved in the biosynthesis of GABA, and by
delaying its metabolism through the suppression of GABA transaminase
and succinic semialdehyde dehydrogenase, which metabolize GABA.
Moreover, VPA enhances the expression of GABA receptors, therefore
amplifying the neuronal response to GABA [13].
3. VPA as an HDAC inhibitor
VPA, as well as other HDAC inhibitors, can alter the expression of
many genes [14]. Corresponding proteins were described to play
important roles in cellular activity and could influence several important
pathways such as cell cycle regulation, differentiation, apoptosis, as well
as DNA repair [15]. Thus, multiple actions were reported in different
research studies. For example, it reduced the action of HDAC6 and
HDAC8 in a cardiac hypertrophy model [9]. In renal fibrosis, VPA
inhibited the effect of HDAC4/5 [16]. It also suppressed the activity of
HDAC1/2 in hepatic fibrosis [17] and HDAC3/4 activity in a penile
fibrosis model [18]. HDAC suppression correlates with beneficial effects
for several neuronal diseases because class I and II HDACs remarkably
affect neuronal activity [4]. VPA can alter DNA methylation by the ac­
tion of DNA methyltransferases, which add a methyl moiety through
S-adenosyl-L-methionine to the 5th carbon of CpG dinucleotide cyto­
sine, which leads to silencing of the gene [19]. VPA was shown to lower
methylated DNA in many cell lines such as neuroblastoma, HeLa, and
HEK 293. Moreover, mice treated with VPA displayed elevated deme­
thylation of DNA in their brains [20].
4. Actions on the cardiovascular system
VPA showed a cardioprotective action (Fig. 1) through its action on
HDACs and its ability to affect genetic regulation [21]. Li et al. studied
the cardioprotective action on a rat renovascular hypertensive model.
VPA (400 mg/kg) ameliorated cardiac dysfunction, cardiac hypertro­
phy, and fibrosis by suppressing the expression of HDAC2, HDAC8,
Fig. 1. The therapeutic potential of valproic acid (VPA) in cardiac dysfunction. VPA inhibits the activity of histone deacetylases (HDACs), which leads to histone
acetylation and relaxation of chromatin structure, resulting in gene expression and shows beneficial outcomes for cardiac arrhythmia, cardiac fibrosis, cardiac
hypertrophy, hypertension and myocardial infarction.
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Biomedicine & Pharmacotherapy 142 (2021) 112021
connective tissue growth factor, and transforming growth factor-β1
[22]. VPA has been shown to attenuate cardiac hypertrophy and fibrosis
by inhibiting HDACs to acetylate the mineralocorticoid receptor in
spontaneously hypertensive rats [23].
At a dose of 300 mg/kg once daily for 4 weeks, VPA suppressed the
sympathetic excitability, reduced cardiac remodeling, and modified left
ventricular work during a pressure overload experimental study
demonstrated by Yang et al. [24]. In transgenic mice, 8 weeks of VPA
administration attenuated atrial remodeling and slowed down atrial
fibrillation. This was attributed to a marked reduction in (a) atrial
dilation and fibrosis, (b) enlargement of cardiomyocytes, and (c)
disarrangement in myocytes’ structure via regulating oxidative phos­
phorylation or RhoA signaling [25].
Tian and his colleagues reported that VPA in a dose of 250 mg/kg in
rats showed a 50% reduction in myocardial infarct volume and
improved systolic blood pressure via HDAC inhibition and Foxm1 gene
expression with improved survival of cardiomyocytes cells [26].
Another study showed a hypotension effect via minimizing the HDAC1
expression and reducing angiotensin II in a high-fat-diet rat model after
6 days of VPA treatment at a dose of 300 mg/kg [27]. Moreover, VPA
blocked sepsis-mediated myocardial dysfunction by accelerating
myocardial autophagy through enhancing the expression of PTEN and
suppressing the AKT/mTOR pathway [28].
5. Action on diabetes mellitus
Diabetes mellitus (DM) is a metabolic disorder characterized by
chronic hyperglycemia with abnormal carbohydrate, fat, and protein
metabolism due to defects in insulin secretion, insulin action, or both.
It is classified into type 1 diabetes mellitus (T1DM) as well as T2DM
[29]. T1DM is mainly caused by autoimmune β-cell damage causing
endogenous insulin deficiency [30]. Autoimmune antibodies that work
against insulinoma antigen II, glutamic acid decarboxylase, insulin, and
the recently characterized zinc transporter VIII, are among the most
D. Singh et al.
efficient biological markers for autoimmune T1DM in both adults and
children [31].
In a daily oral dose of 150 and 300 mg/kg for 3 weeks, VPA improved
glycemic control by suppressing HDAC activity and enhancing the
number of β-cells and their function in the streptozotocin-induced rat
diabetic model [32]. Additionally, VPA also reduced insulin resistance,
fat accumulation, dyslipidemia, and hepatic glucose production in
T2DM, suggesting its effects on peripheral tissues like liver and adipose
tissue [33]. Moreover, studies conducted on Wfs1-knockout mice and
streptozotocin-injected mice showed a reduction in blood glucose level
after administering 300 mg/kg of VPA via insulin enhancing action
[34]. Another study conducted on alloxan diabetic rats treated with VPA
reported glucose-lowering, antihyperlipidemic, and antioxidant effects
[35]. A similar effect was noted in a different study conducted on a
high-fat diet/streptozotocin-treated rats [36].
6. Renal protective effect of VPA
When there is an imbalance between the production of free radicals
and antioxidants, oxidative stress occurs. Consequently, individual
biomolecules are oxidized, and these molecules are structurally and
functionally modified [37]. This oxidizing process is mainly conducted
in the mitochondria, using mitochondrial cytochrome oxidase enzymes
like cytochrome P450. Reactive oxygen species (ROS) products from
such a mechanism probably lead to progressive kidney damage and
atherosclerotic disease resulting in chronic renal disease [38].
In a model of diabetic nephropathy, Sun et al. found that VPA
attenuated diabetes-mediated renal injury through suppressing endo­
plasmic reticulum-induced stress and apoptosis. VPA enhanced the level
of glucose-regulated protein 78 (GRP78) and lowered C/EBP-
homologous protein (CHOP), gene 153, and caspase‑12 levels. This
result might be attributed to histone H4 acetylation regulation in the
promoter site of the GRP78 and CHOP in the endoplasmic reticulum
[39]. Additionally, treatment with VPA had a beneficial effect on
podocyte damage caused by adriamycin in mice by blocking flagellation
and detachment of the podocyte foot process, as well as the glomer­
ulosclerosis process [40]. Furthermore, Khan et al. confirmed the
renoprotective actions of VPA through its ability to reduce podocyte and
renal injuries, specifically by promoting the autophagy process and
deactivation of NF-κB/inducible nitric oxide synthase signal pathway in
a rat diabetic nephropathy model [16].
Speir et al. demonstrated the beneficial effect of VPA against acute
renal ischemia-reperfusion damage in the rat. VPA at a dose of 150 mg/
kg minimized ischemic injury by downregulation of inflammatory cy­
tokines IL1β and IL6 and upregulation of anti-apoptotic molecule Bcl2
and improved renal tissue regeneration [41]. In acute kidney injury
induced by sepsis in mice, VPA (300 mg/kg) effectively ameliorated
kidney damage by minimizing oxidative and inflammatory responses.
VPA treatment reduced renal malondialdehyde and myeloperoxidase
activity while enhancing the level of superoxide dismutase and the
reduced form of glutathione along with minimization in circulating
concentrations of TNFα, IL1β, and IL6 [41].
Epigenetic gene modifications are strongly regulated by histone
deacetylation [42]. The intricate connection between inhibitors of
HDAC action in the epigenetic maintenance and modification of immune
cell gene expression, particularly concerning myeloid cell and T
lymphocyte differentiation and activation, has been well recognized
[43]. Amirzargar et al. have noticed that VPA changed the cytokine
profile and displayed anti-inflammatory action in a rat renal
ischemia-reperfusion damage model. Treatment with VPA minimized
histopathological alteration and serum creatinine level, attenuated the
response of inflammatory mediators, and enhanced the
anti-inflammatory state to support quicker renal recovery due to
ischemic alteration and better improvement of kidney function [44].
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Biomedicine & Pharmacotherapy 142 (2021) 112021
7. Anti-inflammatory effect of VPA
Recent research demonstrated the anti-inflammatory action of VPA
based on a specific molecular and cellular level in post-surgical
inflammation of the conjunctiva, where a mouse conjunctival scarring
model was used to evaluate the effect of VPA. After surgery, VPA was
injected immediately into the sub conjunctiva. It suppressed the gen­
eration of pro-inflammatory cytokines such as CXCL1, IL5, and IL6, the
reduction of IL10, and the TNFα-induced NF-κB [45]. Liu and his col­
leagues explored the protective effect of VPA in a rat model of autoim­
mune encephalomyelitis. VPA reduced inflammatory responses,
minimized microgliosis, repressed activation of NF-κB signal pathway,
and attenuated retinal ganglion cell apoptosis in rats’ optic nerve [46].
VPA minimized the nociception and inflammation in a rodent model of
acute pain and inflammation. The effect of VPA was examined on
carrageenan-induced paw edema and peritonitis. VPA treatment
reduced paw edema and protected tissue structure. Reduced levels of
TNFα and leukocytes and releases of myeloperoxidase in peritonitis
were also observed [47].
8. Neuroprotective effect of VPA
Neural network rhythms are engaged in information processing,
storage, and retrieval, which can be vital for memory consolidation,
executive functioning, and sensory processing. Thus, brain arrhythmias
might have a catastrophic effect on circuit operation, which is consid­
ered the initial symptom of numerous neurological diseases. Further­
more, brain arrhythmia can function as biomarkers for a broad area of
brain disease [48]. Imbalance in acetylation of histone and, as a result,
the malfunction in transcription is related to a large variety of neuro­
degenerative diseases (Fig. 2) [49].
VPA has been shown to enhance white matter renovation and the
formation of neurons after stroke. Administration of VPA 28 days
following middle cerebral artery occlusion (an experimental stroke
model) dramatically improved survival of oligodendrocyte and facili­
tated oligodendrogenesis, resulting in an increased myelinated axon
density in the ischemic penumbra [50]. VPA was reported to attenuate
brain injury in a rat transient focal cerebral ischemia model by inhibiting
HDAC and inducing the level of heat shock protein (HSP). VPA treat­
ment (300 mg/kg) right after ischemia followed by repetitive injections
every 12 h was noticed to diminish infarct size and lower
ischemia-induced neurological insufficiency scores. It also inhibited the
stimulation of caspase-3 [51].
Wang et al. showed that chronic VPA therapy stimulated angiogen­
esis and facilitated functional regeneration after rat ischemic stroke in
the brain. They explained these observations by the ability of VPA to
suppress HDAC and activate hypoxia-inducible factor-1α and its asso­
ciated proangiogenic vascular endothelial growth factor and matrix
metalloproteinase2/9 [52]. A recent study also proved that
VPA-induced suppression of glycogen synthase kinase-3 and HDAC is
responsible for its neuroprotective effect in a rat brain ischemia model
[53]. Moreover, VPA showed a neuroprotective effect against rat global
transient ischemia model by attenuating hippocampal cell loss and
cognitive deficits via reducing ROS production and cerebral inflamma­
tion and repression of HDAC and activation of HSP70 [54].
Ximenes et al. have demonstrated the neuroprotective action of VPA
in the 6-OHDA rat model of Parkinson’s disease. In their study, they
showed that intranigral administration of 6-OHDA to rats enhanced the
release of IL1β, IL6, and TNFα in the striatum, while oral administration
of VPA at 50 mg/kg reduced the level of inflammatory mediators and
decreased neuron degeneration in the striatum owing to the anti-
inflammatory and HDAC inhibitory actions of VPA [55]. Moreover,
VPA displayed a neuroprotective action against rotenone-induced Par­
kinson’s disease. Administration of the mitochondrial toxin, rotenone,
induced injury in dopaminergic neurons while chronic treatment of VPA
reduced the nuclear translocation of synuclein monoubiquitinated
D. Singh et al.
protein in dopaminergic neurons and protected substantia nigra neu­
rons, and increased the level of tyrosine hydroxylase and striatal dopa­
mine level. By enhancing histone H3 acetylation and inhibiting the
HDAC enzyme, VPA was able to increase the expression of neuro­
protective genes [56].
VPA attenuated neuron injury and Parkinson’s disease-like charac­
ters in LRRK2 R1441G transgenic mice. VPA treatment improved his­
tone acetylation levels and the number of tyrosine hydroxylase-
containing neurons in substantia nigra of mice. It also decreased iba-1-
stimulated microglia and the level of pro-inflammatory mediators,
thus improving parkinsonism-associated motor and non-motor deficits
[57]. In vitro, VPA protected dopaminergic SH-SY5Y cells from
MPP+-produced neurotoxicity. Pretreatment with VPA attenuated
MPP+-induced dopaminergic cell death by inhibiting ROS production
via activating CDK5/p35 cascade and ERK signaling pathway [58]. Leng
et al. suggested that VPA could induce α-synuclein in rat cerebral
cortical neurons both in vitro and in vivo via inhibition of HDAC, which
contributed to its neuroprotection against glutamate excitotoxicity [59].
VPA inhibited GSK-3β-mediated γ-secretase cleavage of APP,
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Biomedicine & Pharmacotherapy 142 (2021) 112021
Fig. 2. The beneficial prospects of valproic acid (VPA)
in neurodegenerative disease. VPA blocks the action
of histone deacetylases (HDACs) and leads to tran­
scriptional activation of anti-apoptotic and neuronal
surviving pathways like HSP70, AKT, CDK5, ERK, NF-
κB, and suppression of caspase-3, TNF-α, IL-1β, IL-6,
ROS, and many other factors which cause neuronal
death. HSP70: Heat Shock Protein 70; AKT: Enzyme
serine/threonine protein kinase; CDK5: Cyclin
Dependent Kinase 5; ERK: Extracellular Signal-
regulated Kinases; TNF-α: Tumor Necrosis Factor-α;
IL-1β: Interleukin-1β; ROS: Reactive Oxygen Species;
NF-κB: Nuclear Factor-κB; MMP: Matrix metal­
loproteinases; GSK: Glycogen Synthase Kinase.
decreased Aβ production, reduced neuritic plaque formation, and alle­
viated the memory deficits in AD transgenic mice [60]. VPA improved
the survival rate and abnormal motor activity in a model of Huntington’s
disease. Daily administration of VPA increased the survival of transgenic
mice and restored their reduced involuntary locomotor performance
without showing any prominent adverse effect on their behavior [61].
VPA administration alleviated traumatic brain injury (TBI)-induced
blockade of autophagic flux and increased the autophagy stimulation,
thus inhibiting apoptosis of brain cells and affecting microglial activa­
tion and phenotype polarization to promote post-traumatic functional
recovery and serve as a possible post-traumatic brain injury treatment
[62].
Similarly, another study reported that VPA exerted anti-apoptotic
and neuroprotective effects against TBI by up-regulating ERK and AKT
expression, and these signaling pathways mediate VPA neuroprotection
[63]. VPA showed anti-apoptotic and neuroprotection qualities in
SH-SY5Y cells and primary cortical neurons by inhibiting endoplasmic
reticulum stress and promoting the AKT activity.
Hernandez and his team have revealed the neuroprotective action of
D. Singh et al.
VPA against ischemia-reperfusion injury in the brain of rats. VPA
treatment alters Bcl2 expression and inhibits caspase-3 activation,
which may be a protective mechanism of VPA against apoptosis in
injured neurons [64]. Moreover, VPA was also reported to reduce
apoptosis through up regulation of Bcl2 and down regulation of Bax
expression in developing neurons in a study in which VPA was given to
pregnant rats [65]. This effect is indeed explaining the toxic effects of
VPA (teratogenicity) after fetal exposure.
9. Effect of VPA on drug addiction
Regulation of chromatin arrangement during post-translation alter­
ations of histones acetylation shows up as an essential mechanism to
transform a diversity of environmental stimuli involving drugs of abuse
into specific modification in genetic expression. Changes in the expres­
sion of genes support the occurrence and continuation of the addicted
condition [66]. A study carried out on mice demonstrated that repeated
injections of VPA after methamphetamine might minimize the addictive
behavior. On the other hand, this result was not observed on
cocaine-caused behavior. Such primary outcome displayed that different
abuse drugs have different neural mechanisms, which indicate that VPA
may possess distinct modulating action on methamphetamine and
cocaine addiction in humans [67].
A non-randomized and open-label clinical study has been conducted
to compare the short-term effect of buprenorphine and VPA to a control
group that got a 10-day conventional treatment of clonidine/carba­
mazepine. Sixty-two-drug dependent subjects were included to evaluate
the efficacy of VPA and buprenorphine against drug dependence. The
combined treatment of buprenorphine and VPA appeared to be a
harmless and hopeful method for therapy of several drug withdrawal
symptoms because the combination of both drugs did not affect blood
pressure, pulse, or liver function and displayed no drug interaction and
having few side effects. These outcomes indicate that a combination of
buprenorphine/VPA may be a better de-addiction therapy for with­
drawal symptoms of many drugs than the conventional management
with clonidine and carbamazepine [68].
10. Antimicrobial activity of VPA
Microbial resistance to antibiotics represents a major public health
problem, particularly in developing countries where infectious diseases
still represent a serious cause of human mortality [69]. Antibiotics are
either cytotoxic or cytostatic to pathogenic microorganisms, helping the
body’s normal defenses to eradicate them [70]. VPA displayed a
powerful antifungal effect in a pH-dependent manner towards sensitive
and resistant Candida albicans. VPA exerted a potent anti-biofilm effect
and decreased vaginal epithelium cell damage induced by Candida
albicans and potentiated the effect of antifungals such as terbinafine. The
antifungal activity of VPA was attributed to its ability to interfere with
the fungal vacuoles’ integrity [71]. In a study by Nathiya et al., the
antibacterial action of several anticonvulsant drugs, including VPA, was
tested. VPA displayed high effectiveness against Staphylococcus aureus
and Proteus vulgaris at 100 µg/ml, while other tested organisms required
more than 200 µg/ml. Carbamazepine and gabapentin were not effec­
tive against these isolated bacteria. Therefore, it was concluded that
VPA, among other anticonvulsants, has a unique antibacterial action and
might be useful against certain bacterial infections [72].
11. Anticancer activity
Histone deacetylation and DNA methylation are mechanisms
involved in resistance to chemotherapy through the protection of the
cancerous cells via silencing of crucial anti-tumor genes. It is supposed
that HDAC inhibitors function via stimulation or de-repression of
silenced tumor inhibitor genes [73,74]. HDACs possess a vital impact on
chromatin remodeling and epigenetics, giving their inhibitors an
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Biomedicine & Pharmacotherapy 142 (2021) 112021
important role in cancer research [74]. In MCF-7 breast carcinoma cells,
VPA enhanced the antiproliferative effect of melatonin by inducing the
expression of melatonin receptor MT1 [75]. Terranova et al. found that
VPA at low concentration produced both time and dose-dependent
upregulation of thymidine phosphorylase transcript and protein
expression in breast carcinoma cells. However, this effect was not
recorded in the non-cancer breast MCF-10 cell line. The authors also
found that VPA potentiated capecitabine action in breast carcinoma cells
by inhibiting HDAC3; however, this effect was lost in thymidine phos­
phorylase knockout cells [76].
VPA also showed a synergistic anticancer action with arsenic trioxide
against NCI-H1299 and NCI-H460 lung cancer cells both in vitro and in
vivo. This combination efficiently suppressed the proliferation of lung
cancer cells by arresting the G2/M-phase of the cell cycle and inducing
caspase-dependent apoptosis [77]. Additionally, the combined syner­
gistic action of VPA and gemcitabine was investigated on pancreatic
tumor cells. It was observed that VPA dose-dependently improved the
sensitivity of gemcitabine towards pancreatic tumor cells. Surprisingly,
a low VPA concentration augmented the invasion of pancreatic carci­
noma cells that previously displayed gemcitabine-stimulated motility.
Furthermore, a low VPA dose enhanced the ROS/AKT/STAT3/Bmi1
pathway activation and eventually supported the migration and tissue
invasion of pancreatic tumors caused by gemcitabine [78]. Similarly, a
study evaluated the effect of combining VPA with P276-00, a
cyclin-dependent kinase blocker, on lung cell carcinoma. The results of
this study revealed that this combination is synergistic whether tested on
p53+ or p53- lung cell carcinoma with a significant decrease in colony
formation, up-regulation of tumor inhibitor proteins such as p53, p27,
and p21, and a reduction of the expression of survival proteins like Bcl2
and cyclin D1 [79].
VPA was investigated for anticancer activity (Fig. 3) on the FaO cell
line of rat hepatoma. It induced the death of rat hepatoma cells through
apoptosis in a dose-dependent way. Upregulation of caspase-11 was
enhanced at the transcription level and caspase-3 at the enzyme activity
level, proposing a caspase role in VPA-mediated apoptosis in FaO cells
[80]. In prostate cancer, the combined effect of metformin and VPA
produced more apoptosis and inhibition of prostate PC-3 and LNCaP
cancer cells due to activation of the p53 signaling pathway [81]. VPA
was also found to exert a synergistic effect with metformin in
metformin-resistant renal cancer cells. This effect was attributed to the
ability of VPA to enhance H3 acetylation [82]. In the thyroid cancer cell
line, the anticancer action of VPA was examined on cancer growth and
Notch1 upregulation. VPA showed an ability to activate Notch1
expression, stimulate apoptosis, and suppress cancer cell growth [83].
Michaelis et al. [84] studied the effects of VPA combined with IFN-α
against two neuroblastoma cell lines (NB-2 and UKF-NB-3). They found
that VPA and IFN-α inhibited the growth of UKF-NB-3 xenograft tumors
of nude mice synergistically and promoted complete healing in two out
of six animals, whereas single therapy only repressed tumor growth. In
gastric tumor cells, VPA administration suppressed HDAC1/2 action and
produced enhanced autophagy, which leads to stimulation of apoptosis
through repression of the inhibition of HDAC1/PTEN/AKT signal
transduction pathway [85]. Li and Ma studied the adjuvant effect of VPA
and a diterpenoid oridonin to suppress the proliferation and metastasis
formation of HL-60 leukemia cells. Oridonin showed apoptotic action on
HL-60 leukemia cells by stimulating the intrinsic apoptotic pathways,
while the drug combination also downregulated Bcl2/Bax ratio [86].
VPA also time and dose-dependently enhanced the effect of GANT61
in suppressing the growth of multiple myeloma cells by blocking the
upregulated PTCH1, GLI1, and HES-1 signaling pathway [87]. Inter­
estingly, the anticancer effect of VPA was not only shown in experi­
mental studies but was also included in clinical trials. For example, VPA
in combination with karenitecin, a topoisomerase I inhibitor, underwent
phase I/II clinical study where 47% of melanoma patients on combi­
nation therapy possessed a stable disease with an average
progression-free longevity of 10.3 weeks, while 34% of patients on
D. Singh et al.
single therapy had stable disease with an average progression-free
longevity of 7.9 weeks [88]. VPA also increased the sensitivity of can­
cer cells to chemotherapy, produced growth arrest, induced the
apoptosis of glioma cells, and improved the survival rate of patients in a
clinical trial when given in combination with one or more chemother­
apeutic agents with advanced melanoma [89].
In one clinical trial on patients with acute myeloid leukemia, 11 out
of 36 patients (average age 77) unsuitable for normal intensive
chemotherapy showed response to a combination of VPA, all-trans ret­
inoic acid, and a lower dose of cytarabine. It was noted that the drug
combination was associated with a low frequency of adverse effects and
complete remission in two patients [90]. A study conducted in 2013
indicated that VPA could reduce the maximum tolerated dose of tem­
sirolimus in pediatric patients with solid tumors. The combined treat­
ment was well tolerated and maintained the blocking effect of
temsirolimus with a minimal degree of toxicity on normal CD34+ he­
matopoietic precursors, confirming their valuable and safe role in
treating B lymphoma [91].
Maintained VPA trough concentrations of 75–100 μg/ml in children
with refractory solid tumors in phase I study was well-tolerated.
Hyperacetylation of histone in peripheral blood mononuclear cells was
recorded in half of the studied patients [92]. A phase II clinical study was
conducted to assess the advantages of adding VPA to weekly paclitaxel
in patients with gastric cancer. In this study, no significant advantage
was observed between the weekly paclitaxel (median overall survival
9.8 months) and the weekly paclitaxel plus VPA (median overall survival
8.7 months) [93]. VPA reduced the frequency of myeloid-derived sup­
pressor cells, accompanied by the down-regulation of TLR4 mRNA
expression [94].
12. Protective role of VPA in muscular dystrophy
Muscular dystrophies consist of a distinct class of genetic disorders,
which results in muscle degeneration with impaired function [95].
HDAC can control gene transcription in muscular progenitor cells via
managing the action of myogenic regulatory factors and myocyte
enhancer factor-2 family proteins [96]. VPA administration reduced
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Biomedicine & Pharmacotherapy 142 (2021) 112021
Fig. 3. The favorable role of valproic acid
(VPA) in cancer. VPA has an important impact
on cancer prevalence by activating p53, PTEN,
Bax, caspase-3, ROS, p21, and p27, which leads
to cancer cell cycle arrest, growth, and
apoptosis. VPA also inhibits cyclin D1, AKT,
STAT, TNF-α, NF-κB, and Bcl2, which cause
cancer survival by blocking the apoptosis
pathway. PTEN: Phosphatase and Tensin ho­
molog deleted on chromosome 10; Bax: Bcl2
associated X; caspase-3: cysteine aspartic
protease-3; ROS: Reactive Oxygen Species;
AKT: Enzyme serine/threonine protein kinase;
TNF-α: Tumor Necrosis Factor-α; STAT: Signal
Transducers and Activators Transcription; NF-
κB: Nuclear Factor-κB; Bcl2: B cell lymphoma 2.
fibrosis, hind limb spasms, improved sarcolemmal integrity, and
reduced CD8+ inflammatory cells in Duchenne muscular atrophy mice.
Moreover, VPA displayed protective effects on the myotubes of skeleton
muscle, activated AKT signaling, enhanced gene transcription and pro­
tein synthesis, and promoted cell longevity by inhibiting apoptosis [97,
98]. Additionally, VPA was found to improve muscle wasting produced
during cancer cachexia in mice by inhibiting C/EBPβ binding to
ubiquitin-ligase MAFbx/atrogin promoter and enhancing protein anab­
olism by inducing AKT phosphorylation [99]. A phase II open-label trial
of VPA concluded that the drug might be used safely in patients with
spinal muscular atrophy older than 2 years. There was some evidence in
support of improvement in motor function in younger non-ambulatory
children [100].
13. Other activities
13.1. Effect on eyes
In rat models of retinal ischemia/reperfusion injury induced by
increasing intraocular pressure, pretreatment with 300 mg/kg subcu­
taneous VPA reduced retinal damage [101]. Subsequent studies
demonstrated that VPA attenuates retinal injury by promoting antioxi­
dant effects, anti-apoptotic pathways via histone H3 acetylation, and the
up-regulation of HSP70 [102,103].
13.2. Effect on lungs
In a rat model of acute lung injury induced by superior mesenteric
artery occlusion, VPA has been shown to improve survival and mitigate
lung injury through ROS reduction and anti-inflammatory effects [104].
VPA treatment also provided pulmonary protection by expressing the
antioxidant heme oxygenase 1 after ischemia/reperfusion injury [105].
13.3. Effect on muscles
VPA has been found to alleviate muscle wasting in rodents’ models of
cancer cachexia and myotubes exposed to conditioned medium from
D. Singh et al.
cachexia-inducing cell lines. Notably, VPA prevented an up-regulation
of muscle C/EPBβ expression in these models [99, 106–108].
13.4. Effect on hormones
Lagace et al. demonstrated that VPA decreases in a dose-dependent
manner leptin secretion and leptin mRNA levels in adipocytes in vitro,
suggesting that VPA therapy may be associated with altered leptin ho­
meostasis contributing to weight gain in vivo [109].
13.5. In silico studies
Elbadawi and associates reported a possible activity of VPA against
Plasmodium falciparum HDAC1. They proposed that VPA would also
have anti-leishmanial activity mediated by inhibiting Leishmania dono­
vani class I HDAC [110]. In silico docking study reported that
VPA-induced inhibition to GABA transaminase and succinate semi­
aldehyde dehydrogenase are mainly responsible for up-regulating GABA
expression to play an anticonvulsant effect [111].
14. Conclusion
VPA was brought up to clinical practice 5 decades ago by chance.
Today, VPA is utilized to treat many diseases, and its tolerability and
utility across ailments are well established. Information from many
preclinical and clinical trials indicates that VPA might have actions
mediated through molecular mechanisms that are yet unknown. Besides
the advancement of innovative antidiabetic, neuroprotective, car­
dioprotective along with other healing substances with HDAC inhibiting
properties, well-designed randomized control trials are required to
verify the effectiveness of VPA as adjuvant therapy for various disorders.
Data on pharmacokinetics, half-life, oral bioavailability, and adverse
reactions of VPA during chronic therapy are available.
Interestingly, the VPA has both pro-apoptotic and anti-apoptotic
properties. In several neuroprotective studies, VPA showed anti-
apoptotic effects by activation of Bcl2, HSP70, CDK5, ERK, AKT
pathway and inhibition of caspase-3, Bax, ROS, and endoplasmic retic­
ulum stress, whereas in anticancer studies, VPA exerted its action
mechanism through activation of caspase-3, Bax, p21, endoplasmic re­
ticulum stress and ROS formation and inhibition of Bcl2, cyclin D1, and
AKT. This may be due to different signaling mechanisms between
normal and cancer cells.
Several publications introduced the beneficial actions of VPA and its
potential side effects such as hepatotoxicity, aplastic anemia, coagulo­
pathies, and teratogenic effects. Some preexisting pathologies, including
coagulopathy or hyperhomocysteinemia and pregnancy, are common
contraindications to VPA usage as a treatment. Balancing therapeutic
potentialities with extreme side effects observed following usage of VPA
to favor the beneficial effects will undoubtedly prove to be a complex
and challenging problem for medical management.
15. Future prospective
From all the previously stated effects, VPA seems to be a pleiotropic
agent with multiple mechanisms of action and protective effects against
a number of disease models. Inflammation and oxidative stress are the
main pathways in almost all human diseases, so agents possessing the
ability to counteract these pathways are expected to have beneficial
effects in many disease states. VPA was proved to exert these effects,
which is why we found these diverse pharmacological activities.
Recent reviews suggested the beneficial effect of VPA in SARS-Cov-2
viral infection based on its anti-thrombotic and anti-inflammatory ef­
fects [112–114]. An in vitro study using human umbilical veins and
coronary artery endothelial cell culture showed that VPA treatment
reduced ACE-2 expression in endothelial cells and the expression of in­
flammatory cytokines IL6 along with the endothelial activation marker
7
Biomedicine & Pharmacotherapy 142 (2021) 112021
ICAM-1, suggesting its potential as a therapeutic agent during Covid-19
infection [115]. A short open-label clinical trial was conducted on
Covid-19 patients who showed promising effects on fatality and hospital
stay length [116].
Funding
No funding was received from any source.
Author Contributions
Conceptualization, Dhirendra Singh and Sumeet Gupta; literature
review, Dhirendra Singh, Sumeet Gupta, Mohamed A. Morsy, Anroop B.
Nair and Al-Shaimaa F. Ahmed; writing–original draft preparation,
Dhirendra Singh and Sumeet Gupta; Writing–review & editing, Sumeet
Gupta, Mohamed A. Morsy, Anroop B. Nair and Al-Shaimaa F. Ahmed.
All authors read and approved the final manuscript.
Conflict of interest statement
The authors report no declarations of interest.
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